TTB F 5200.17 Bond -- Drawback of Tax on Tobacco Products, Cigarette P

OMB No. 1513-0026 (xx/xx/xxxx)

1. AMOUNT OF BOND

DEPARTMENT OF THE TREASURY

ALCOHOL AND TOBACCO TAX AND TRADE BUREAU
BOND -- DRAWBACK OF TAX ON TOBACCO PRODUCTS, CIGARETTE PAPERS, OR TUBES
(See Instructions on Page 2.)

2. PRINCIPAL

3. ADDRESS (Number, Street, City, State, ZIP Code)

4. NAME OF SURETY

5. LOCATION OF PRODUCTS (Number, Street, City, State, ZIP Code)

KNOW ALL MEN BY THESE PRESENTS, That we, the above-named principal and surety, are held and firmly bound unto the United
States of America in the above-named amount, lawful money of the United States, for the payment of which we bind ourselves, our heirs,
executors, administrators, successors, and assigns, jointly and severally, firmly by these presents.
Whereas, the said principal makes claim, as identified below, for allowance of drawback of Internal Revenue tax paid on tobacco products,
cigarette papers, or cigarette tubes, subject to drawback of tax under Title 26 United States Code.
IDENTIFICATION OF CLAIM

AMOUNT

DATE

LOCATION OF DIRECTOR,
NATIONAL REVENUE CENTER, ALCOHOL
AND TOBACCO TAX AND TRADE
BUREAU, WITH WHOM FILED

KIND OF ARTICLES

TO BE SHIPPED TO
(Name and Address)

NOW, THEREFORE, if the said articles or any part thereof, be not relanded at any port or place within the United States, and if the claimant
or his legal representative must produce, as required by the applicable regulations, evidence satisfactory to the Director, National Revenue
Center that the said articles have been landed at some port without the jurisdiction of the Internal Revenue laws of the United States, or that
after clearance from the United States the same were lost (otherwise than by theft), then this obligation must be void; otherwise, it must
remain in full force and effect.

Witness our hands and seals this
Signed, sealed, and delivered in the presence of-

day of

, 20

.
(SEAL)
(SEAL)
(SEAL)
(SEAL)

TTB F 5200.17 (01/2022)

Page 1 of 2

DIRECTOR, NATIONAL REVENUE CENTER
I approve the foregoing bond, which has been executed in due form and in compliance with laws and regulations.
6. SIGNATURE OF DIRECTOR, NATIONAL REVENUE CENTER, ALCOHOL AND TOBACCO TAX AND TRADE BUREAU

7. DATE APPROVED

INSTRUCTIONS
1.

This bond must be filed in duplicate with the Director, National
Revenue Center, Alcohol and Tobacco Tax and Trade Bureau,
550 Main Street, Ste. 8002, Cincinnati, OH 45202-5215 for each
claim for drawback filed under 27 CFR Part 44.

2.

The bond may be given with corporate surety authorized to act as
surety by the Secretary of the Treasury, or by the deposit of
transferable bonds or notes of the United States. The United States
Code (6 U.S.C. 15) provides that "the phrase 'bonds or notes of the
United States' shall be deemed * * * to mean any public debt
obligations of the United States and any bonds, notes, or other
obligations which are unconditionally guaranteed as to both interest
and principal by the United States.”

3.

If any alteration or erasure is made on this bond before it is
executed, the principal and the surety must incorporate in the bond
a statement specifically identifying the nature of the change. If any
alteration or erasure is made on this bond after it is executed, the
consent of all parties thereto must be written in the bond.

4.

The principal must be identified by stating the full name, if an
individual; by stating the firm name and the full name of each
partner or member, if a partnership or association; or, if a
corporation, by stating the corporate name, the name of the State
under the laws of which it is organized, and the address of the
principal office.

5.

The amount of the bond must not be not less than the amount of tax
for which drawback is claimed.

6.

The bond must be executed in duplicate by the principal and by the
surety in the following manner:
(a) If the principal is an individual, either he/she or his/her
authorized attorney-in-fact must sign the bond. The signature
must be affixed in the presence of two persons who must sign
the bond as witnesses.

(c) If the principal is a corporation, the corporate name must be
typed or written and must be followed by the word "by" and the
signature and the title of the officer of the corporation who has
been authorized to act in its behalf, or the signature of the
empowered attorney-in-fact. If the corporation has a corporate
seal, the signature for the principal must be attested under
corporate seal. If the corporation has no corporate seal, that fact
must be stated following the name of the corporation and in such
case, the signature of the person executing the bond for the
corporate principal must be affixed in the presence of two
persons who must sign the bond as witnesses.
(d) The name of the corporate surety must be typed or written and
must be immediately followed by the word ''by" and the signature
and the title of the officer of the corporation who has been
authorized to sign, or the signature of an empowered attorneyin-fact. The signature for the
surety must be attested under corporate seal.
7.

If the bond is signed by an attorney-in-fact for the principal or by
one of the members for a partnership or association, or by an
officer for a corporation, the authorization for the person to sign
(authenticated power of attorney, resolution of the board of
directors, except of the bylaws, or other document) must be filed
with the bond, unless such authorization has been previously filed
with the Director, National Revenue Center in which event a
statement to such effect must be attached to the bond.

8.

After this bond is approved by the Director, National Revenue
Center, a copy will be returned to the principal.

9.

All correspondence about the filing of this form or any subsequent
action, including termination affecting this bond, should be
addressed to the Director, National Revenue Center, Alcohol and
Tobacco Tax and Trade Bureau, with whom the bond is filed.

(b) If the principal is a partnership or an association, the firm name
must be typed or written and must be followed by the word "by"
and the signatures of all partners or members, or the signature
of any partner or member authorized to sign in behalf of the firm,
or the signature of an empowered attorney-in-fact. Each
signature must be affixed in the presence of two persons who
must sign the bond as witnesses.

PAPERWORK REDUCTION ACT NOTICE
This request is in accordance with the Paperwork Reduction Act of 1995. This bond is required to obtain drawback of taxes on
articles which are exported. This information is required to obtain a benefit by 26 U.S.C. 5706.
The estimated average burden associated with this collection of information is 1 hour per respondent or recordkeeper depending on
individual circumstances. Comments concerning the accuracy of this burden estimate and suggestions for reducing this burden
should be addressed to the Paperwork Reduction Act Officer, Regulations and Rulings Division, Alcohol and Tobacco Tax and Trade
Bureau, 1310 G Street, NW., Box 12, Washington, DC 20005 (please do not send completed forms to this address).
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a
current, valid OMB control number.

Page 2 of 2

TTB F 5200.17 (01/2022)